rattyvonratkins
New
I've been trying to research HPI documentation tips for newborns with Retinopathy of Prematurity. The provider is wondering why I keep down-coding her IP visits and it's because I don't think her documentation meets History requirements for an initial exam, let alone initial L2 or L3. In particular, the HPI is troublesome since there are no visible symptoms for ROP, let alone specific complaints from the patient! Can anyone share how they document comprehensive-level HPI for newborns with ROP?
This is a typical HPI example from one of this MD's chart notes. Is there any advice I can offer this provider on how to expand on HPI for newborns who have no discernable, outward ROP symptoms? Or if I'm the one who's missing something/misunderstanding, please let me know. Thank you in advance!
INFANT INFORMATION
Gestational Age: 25w2d
Current Age: 47 days
Birth Weight: 690 g (1 lb 8.3 oz)
Apgar 1 minute: 4
Apgar 5 minute: 5
Delivery Type: C-Section, Classical
HPI
Prematurity; at risk for Retinopathy of Prematurity based on gestational age and birth weight
This is a typical HPI example from one of this MD's chart notes. Is there any advice I can offer this provider on how to expand on HPI for newborns who have no discernable, outward ROP symptoms? Or if I'm the one who's missing something/misunderstanding, please let me know. Thank you in advance!
INFANT INFORMATION
Gestational Age: 25w2d
Current Age: 47 days
Birth Weight: 690 g (1 lb 8.3 oz)
Apgar 1 minute: 4
Apgar 5 minute: 5
Delivery Type: C-Section, Classical
HPI
Prematurity; at risk for Retinopathy of Prematurity based on gestational age and birth weight